Anatomical and clinical research progress of the lateral supramalleolar perforator flap

Abstract

Background

The lateral supramalleolar perforator flap has evolved significantly since its introduction. Initial descriptions focused on its basic vascular anatomy and surgical technique. However, over time, advancements in imaging technology and surgical techniques have led to a deeper understanding of its vascular patterns and potential modifications.

Methods

To conduct this review, a comprehensive literature search was conducted using electronic databases such as PubMed, Scopus, and Embase.

Results

The review has highlighted various surgical designs and transfer techniques that have been developed to optimize the flap’s effectiveness in different clinical scenarios.

Conclusion

This study provides a theoretical basis for further research and the development of lateral supramalleolar perforator flap.

Introduction

The lateral supramalleolar perforator flap, first proposed by the French scholar Masquelet in 1988, is a flap supplied by the perforating branches of the peroneal artery emerging from the distal interosseous membrane. ¹ This flap has been widely used in clinical practice owing to its ability to repair defects in the lower leg, ankle, and foot without damaging major vessels. ¹ Although extensive studies have confirmed its vascular supply, recent research suggests that its blood source is not solely derived from the peroneal artery but may also involve contributions from the tibiofibular syndesmosis and anastomotic networks with other ankle vessels.^2–7 Consequently, clinicians have developed various modified designs and transfer techniques for this flap. This review has summarized the extensive clinical applications of the flap, demonstrating its versatility in repairing defects in the lower leg, ankle, and foot.

Survey methodology

To conduct this review, a comprehensive literature search was conducted using electronic databases such as PubMed, Scopus, and Embase. The search terms included “lateral supramalleolar perforator flap,” “peroneal artery,” “vascular patterns,” “surgical design,” and “clinical applications.” Inclusion criteria were studies whose primary focus was the lateral supramalleolar perforator flap; those reporting vascular anatomy, surgical design, or clinical outcomes; and peer-reviewed original articles, case series, or systematic reviews in English or Chinese. Exclusion criteria comprised animal or ex-vivo studies, conference abstracts, letters, editorials, duplicate publications, and articles from which complete data could not be extracted. The search period spanned from January 1988 to May 2024. Relevant articles published from 1988 to the present day were carefully selected based on their relevance, quality, and scientific merit. The articles were then analyzed to extract information on the historical evolution, vascular patterns, surgical techniques, and clinical outcomes of the lateral supramalleolar perforator flap. This information was analyzed to obtain a comprehensive summary of the current understanding and practices related to this flap.

Results

History and development of the supramalleolar perforator flap

In 1983, Donski and FogdeStam ⁸ first proposed the presence of a peroneal artery perforator emerging from the posterior intermuscular septum of the lower leg approximately 5–10 cm above the lateral malleolus. They hypothesized that this could serve as the basis for the supramalleolar perforator flap, although it was later confirmed to be a peroneal artery flap. In 1985, Carriquiry initiated studies on the vascular supply of the skin in the supramalleolar region. ⁹ In 1988, the French scholar Masquelet ¹ was the first to report that the supramalleolar flap was supplied by an anterior perforator originating from the distal peroneal artery. Masquelet et al. ¹ subsequently applied this flap clinically to repair soft tissue defects of the dorsum of the foot, ankle, and heel, demonstrating excellent outcomes. This led to the widespread clinical application of the supramalleolar perforator flap.

In 1990, Shizhen and Dachuan revealed, based on anatomical studies, the consistency of the terminal perforators of the peroneal artery and their anastomotic connections with the subcutaneous vascular network and superficial peroneal artery in the distal lower leg. ² This provided an essential anatomical basis for the local transfer of the supramalleolar perforator flap for reconstructing defects of the dorsum of the foot, ankle, and heel. Between 1990 and 1991, Chinese researchers reported successful cases of supramalleolar perforator flaps used for foot dorsum reconstruction, further verifying the presence of consistent perforator vessels in this region. ²

In 1998, Ning et al. conducted further anatomical research on the relationship between the supramalleolar cutaneous branch and peroneal artery perforators. ³ They found that at approximately 5.7–7 cm above the lateral malleolus, the terminal perforator of the peroneal artery divides into ascending and descending branches. The descending branch travels beneath the deep fascia along the groove between the talar eminence and the lateral malleolus, where it anastomoses with the anterior–lateral malleolar artery. Consequently, many domestic and international studies have concluded that the supramalleolar perforator flap primarily derives its blood supply from the terminal perforators of the peroneal artery via the interosseous membrane. This understanding led to the assumption that if the peroneal artery were damaged, the supramalleolar perforator flap would not be suitable for foot defect reconstruction. However, some clinical studies have reported flap survival even in the presence of peroneal artery injury, raising the question of whether alternative vascular supplies exist for this flap. In 1997, Fahui et al. suggested that cutaneous branches from the anterior tibial artery also contribute to the vascular supply of the supramalleolar region. ⁴ With the increasing clinical application of the supramalleolar perforator flap in recent years, its vascular anatomy has garnered significant research interest. Many scholars have challenged the notion that its blood supply is exclusively derived from peroneal artery perforators. Kai et al. ⁶ conducted anatomical studies and proposed that the cutaneous branches of the supramalleolar perforator flap are associated with both anterior tibial and peroneal arteries. They classified these vascular patterns into the following two types:

Arterial arch type

The cutaneous branches of the supramalleolar flap or their common trunk with the descending branch originate from an arterial arch proximal to the distal tibiofibular syndesmosis. This type is further divided into the following three subtypes based on the relative diameters of the arterial arch at the origin: (a) type Ia: balanced type; (b) type Ib: peroneal artery–dominant type; (c) type Ic: anterior tibial artery–dominant type.

Peroneal artery type

Zhigang et al. further explored the vascular anatomy of the lower leg and found that skin perfusion follows a reticular distribution pattern, where interconnected vascular networks extend the perfusion radius of each arterial branch, thereby enhancing skin blood supply. This raises the question of whether the supramalleolar perforator flap also participates in such a vascular network. ⁵

In 2002, Yudong et al. elucidated the anastomotic connections between the lateral tarsal artery and the anterior–lateral malleolar artery. They identified a vascular network in the anterior–lateral malleolar and lateral dorsum of the foot regions, formed by four primary vessels and their branches: ⁷

Peroneal artery perforator: This perforator emerges through the interosseous membrane at approximately 5 cm above the lateral malleolus, courses through the anterior–lateral intermuscular septum, and divides into ascending and descending branches. The descending branch, approximately 1.0 mm in diameter, travels beneath the deep fascia and anastomoses with the anterior–lateral malleolar and lateral tarsal arteries near the ankle groove and sinus tarsi.

Anterior–lateral malleolar artery: Originating from the dorsalis pedis artery at approximately 1.5 cm above and below the ankle joint line, with an external diameter of approximately 1.3 mm, this artery anastomoses with the descending branch of the peroneal artery perforator in the anterior–lateral region.

Lateral tarsal artery: Arising from the dorsalis pedis artery approximately 2.5 cm below the ankle joint line, with an external diameter of approximately 1.5 mm, these arteries form both large direct anastomoses and extensive fine vascular networks.

Lateral calcaneal artery: This artery, which is a terminal branch of the peroneal artery, approximately 0.2 mm in diameter, perforates the deep fascia between the Achilles tendon and the lateral malleolus, extending along the lateral surface of the calcaneus to the fifth metatarsal tuberosity, where it divides into numerous small branches that anastomose with the lateral tarsal artery.

The formation of this vascular network provides a reliable anatomical basis for modifications of the supramalleolar perforator flap in clinical practice.

Over the past three decades, the lateral supramalleolar perforator flap has been almost synonymous with a “peroneal–artery–perforator pedicle flap.” Emerging evidence has revealed that its vascular logic is not a single axial pattern, but rather a multi-source, reticular system involving the peroneal, anterior tibial, dorsalis pedis, and lateral calcaneal arteries. This paradigm shift carries disruptive implications for preoperative design and postoperative complication control. Consequently, the lateral supramalleolar perforator flap has evolved from a “single-perforator” concept into a multi-source, reticular vascular network. Individualized preoperative vascular mapping, dynamic perfusion matching, and defect size–to–vascular pattern coupling will be pivotal in improving success rates and minimizing donor site morbidity. Systematic, prospective studies will ultimately transform this flap from an “experience-based” to a “precision” flap.

In summary, the development of the supramalleolar perforator flap has provided clinicians with additional options for reconstructing defects in the lower leg and foot. With advancements in anatomical research, the preoperative design, transfer methods, and reconstruction techniques for this flap continue to evolve and improve.

Preoperative design and considerations for the supramalleolar perforator flap

The supramalleolar artery perforator flap can be clinically applied in the following two forms: pedicled transfer and free transplantation. Pedicled transfer can further be categorized into antegrade and retrograde transfer types. The design of the flap follows the principles of point, line, and surface. The “point” of the supramalleolar perforator flap refers to the perforator emergence site of the vascular supply, which can be identified using handheld ultrasound, Doppler ultrasound, or computed tomography. Based on the theoretical foundation that the vascular supply of the supramalleolar perforator flap originates from the terminal perforators of the peroneal artery through the interosseous membrane, there are commonly two pedicled transfer methods:

Using the supramalleolar perforator branch as the pedicle: The pivot point is located 5–7 cm above the lateral malleolus. The flap is aligned along the anterolateral intermuscular septum of the lower leg, with its anterior margin within the plane of the tibial crest, the posterior margin generally not extending beyond the posterior border of the fibula, the superior border reaching the upper third of the lower leg, and the inferior boundary extending to the level of the ankle joint. ¹⁰

Using the descending branch of the peroneal artery as the pedicle: The pivot point is located below the lateral malleolus and is determined via ultrasound localization. The flap axis is defined by shifting 2 cm medially from the line connecting the lateral malleolus to the fibular head. ¹¹ The flap is designed based on the wound shape, size, and distance from the pivot point, allowing retrograde repair of foot defects using the descending branch of the peroneal artery perforator. The harvested flap should be 10%–20% larger than the recipient site to compensate for skin contraction and increased flap tension after harvest. ¹²

Based on anatomical studies, Kai et al. proposed that the supramalleolar perforator branches mainly arise from an arterial arch formed by the peroneal and anterior tibial arteries at the proximal level of the distal tibiofibular syndesmosis. This indicates that its vascular supply originates from both peroneal and anterior tibial arteries. Based on this, a new pedicled flap transfer technique was designed as follows: ⁶

Ligating and severing the fibular-side arterial arch at the perforator origin while preserving the tibial-side arterial arch as the pedicle: The flap and its vascular pedicle are tunneled submuscularly to the intermuscular space between the flexor hallucis longus and tibialis anterior or between the tibialis anterior and the tibia to repair soft tissue defects on the medial aspect of the lower leg.

Ligating and severing the anterior tibial artery proximal to the tibial-side arterial arch while preserving the distal anterior tibial artery as the pedicle for distal defect repair.

Ligating and severing the anterior tibial artery distal to the tibial-side arterial arch while preserving the proximal anterior tibial artery as the pedicle for proximal defect repair.

Based on the literature review, the vascular supply of the supramalleolar flap benefits from the extensive vascular network of the lower leg. The supramalleolar artery is not merely a terminal branch perforating from the interosseous membrane via the peroneal artery; in 90% of cases, it is part of a tibiofibular arterial network formed via anastomosis with the anterior tibial artery. This explains the high survival rate observed in clinical practice when designing the flap axis by shifting 2 cm medially from the line connecting the fibular head to the tibial crest. However, anatomical variations exist; in cases where the anterior tibial artery is absent, the terminal branch of the peroneal artery is the sole vascular supply. This vascular variability should be carefully considered when harvesting the flap. Additionally, the supramalleolar artery forms a vascular network with the lateral calcaneal artery, lateral tarsal artery, and anterior–lateral malleolar artery, providing a theoretical basis for lowering the pivot point to repair distal foot defects. However, due to the small caliber of the supplying vessels, the flap should preferably be transferred using an open dissection technique to avoid pedicle compression. Moreover, meticulous hemostasis is essential to prevent postoperative hematoma formation and subsequent pedicle compression owing to localized swelling.

Clinical observations indicate a high survival rate when the flap is positioned posterior to the lateral malleolus for defect repair. However, the vascular axis and perforator localization differ from the sural nerve flap design, effectively ruling out sural nerve–based perfusion. This raises the question of whether the supramalleolar perforator flap also receives vascular supply from posterior perforators. Literature suggests that when utilizing the supramalleolar vascular network as the primary supply for a low-pivot rotation flap, care must be taken to preserve the superficial peroneal nerve to prevent sensory loss or impairment on the dorsum of the foot. Additionally, when dissecting the distal portion of the free flap, it is advisable to include the deep fascia to prevent distal venous congestion and ischemic necrosis. ¹³ Based on these findings, it is hypothesized that the vascular supply in this region originates from longitudinal vascular chains formed by musculoperforators of the peroneal artery within the deep fascial layer, which anastomose inferiorly with the lateral Achilles tendon vascular network. This hypothesis warrants further investigation.

Clinical application of the superior lateral malleolar perforator flap

Pedicled transfer of the superior lateral malleolar perforator flap for anterograde and retrograde wound reconstruction

In 1984, Yoshimura et al. ¹⁴ first reported the use of a reverse island peroneal artery flap for repairing foot and ankle defects. In 2005, Shimin et al. ¹⁵ conducted anatomical studies and found that the terminal branch of the peroneal artery at 1–2 cm above the tip of the lateral malleolus consistently contains perforators with a diameter >0.5 mm, enabling the harvesting of a peroneal artery perforator flap with a lower rotation point, thereby minimizing donor site morbidity. Similarly, in 2013, the Indian surgeon Purushothaman ¹⁶ identified 2–4 perforators within the region 1–2 cm above the lateral malleolar tip and utilized these perforators to design a flap for small calcaneal defects using V-Y advancement and propeller flap techniques. These methods allow direct wound closure while reducing donor site morbidity.

As the dorsum of the foot is a non–weight-bearing area, when using the superior lateral malleolar perforator flap to reconstruct small dorsal foot wounds, the flap is designed without incorporating the superficial peroneal nerve, preserving the sensory function of the innervated area. However, for large dorsal foot defects, the sensory distribution of the superficial peroneal nerve is already severely damaged; therefore, incorporating the nerve into the flap not only facilitates the recovery of sensory function but also increases the flap harvest area and improves the survival rate. ¹⁷

Modified superior lateral malleolar perforator flap (designed based on the descending branch of the superior lateral malleolar perforator)

The modified superior lateral malleolar perforator flap primarily relies on the descending branch of the superior lateral malleolar perforator for blood supply and features a lower pivot point. Literature has indicated that compared with the traditional superior lateral malleolar perforator flap, this method allows the pivot point to be lowered by approximately 7 cm, making it suitable for distal foot wound reconstruction or larger retrograde flap repairs.

Zhibin et al. ¹⁸ compared the clinical outcomes of conventional and modified superior lateral malleolar perforator flaps in the repair of foot and ankle wounds. They concluded that although traditional flaps offer advantages such as straightforward suturing and no damage to the main arterial trunk, they cause significant donor site morbidity and may impair distal sensation postoperatively. The modified superior lateral malleolar perforator flap represents an innovation that changes the pivot point location, shifting it approximately 3 cm lower than that using the traditional method and extending the flap approximately 5 cm downward. This approach ensures adequate flap perfusion, improves survival rates, and prevents lateral foot sensory deficits.

Jingshun and Shenghe ¹⁹ noted that the modified flap’s pivot point is closer to both the wound and the donor site, allowing for a smaller flap harvest area, improved flap perfusion, enhanced local circulation, and reduced postoperative swelling and pain, thereby shortening recovery time. Jianghua et al. ²⁰ demonstrated that shifting the pivot point to the vicinity of the sinus tarsi significantly increases the pedicle volume and reduces compression-related complications. However, excessive lowering of the pivot point may damage the superficial peroneal nerve, leading to sensory deficits in its innervation area. Some studies suggest that incorporating the superficial peroneal nerve when harvesting the flap can enhance blood supply, enabling cross-region perfusion and increasing the harvestable area. ²¹ However, when harvesting this flap, it is crucial to protect the vascular network at the sinus tarsi to avoid compromising blood supply. Additionally, a 3–4 cm-wide fascial cuff should be preserved around the vascular pedicle to prevent vascular torsion and ischemic complications. Given the delicate venous structure, the pedicle should be carefully rotated to avoid folding, twisting, or excessive tension, which may impede venous return and cause congestion. ²²

Propeller flap based on the superior lateral malleolar perforator

In 1991, the Japanese scholar Pignatti et al. ²³ introduced the concept of a propeller flap. Subsequent research integrated the perforator flap technique with the propeller flap concept, proposing a perforator-based propeller flap capable of 180° rotation, which has yielded favorable outcomes in reconstructing distal limb defects.^24–26

The peroneal artery–based superior lateral malleolar perforator propeller flap is designed with a pivot point located 5–6 cm above the lateral malleolus. The flap axis follows a line from the midpoint between the Achilles tendon and the lateral malleolus to the popliteal fossa. ²⁷ The major blade length of the flap should exceed the distance from the pivot point to the farthest defect margin by at least 20% to compensate for tissue contraction after harvesting. ²⁸

This propeller flap is advantageous owing to its relatively constant perforator anatomy, minimal vascular variability, similarity in texture to plantar skin, and ease of harvesting. ²⁹ Xu et al. successfully used the superior lateral malleolar perforator propeller flap to perform repair in six cases of plantar and heel defects following melanoma excision, with favorable clinical outcomes. ³⁰ Yang et al. used this flap for pediatric wound reconstruction and found that although the design and surgical approach were similar to those in adults, certain unique pediatric considerations were noted. In children, the perforator dissection plane is deeper, the peroneal and posterior tibial artery perforators are more consistent, and the flap’s vascular chain functions axially. ³¹ Even when the peroneal artery trunk is injured but distal blood flow remains intact, a perforator-based propeller flap can be harvested.

However, pediatric patients have thicker subcutaneous fat, which increases the risk of perforator injury when harvesting the flap at the superficial fascial level. For younger or obese children, ensuring vascular safety necessitates flap harvesting at a deeper plane, specifically below the deep fascia and above the muscle. ³² However, due to the inclusion of more adipose tissue, these flaps may appear bulkier.

Meticulous surgical handling is crucial for reducing venous complications in pediatric propeller flaps. Postoperative interventions such as flap bleeding, venous thrombolysis, and anticoagulation therapy can effectively manage venous congestion. However, excessive anticoagulation may cause blood loss and coagulation disturbances, increasing the risk of severe complications. Therefore, intraoperative precautions should focus on preventing vascular pedicle compression, ensuring proper postoperative monitoring, and promptly addressing any vascular complications. ³³

Free transfer of the superior lateral malleolar perforator flap for wound reconstruction

With the advancement of industrialization, the incidence of hand trauma has risen due to the widespread use of machinery in factories. Superior lateral malleolar perforator flaps have been adapted into ultra-thin free flaps for reconstructing hand skin defects and performing functional restoration, offering significant clinical advantages. ³⁴

Owing to its excellent pliability, minimal subcutaneous fat, and thin profile, the superior lateral malleolar perforator flap can be harvested as an ultra-thin free flap containing only the perforator vessels, cutaneous nerves, and a small amount of adipose tissue. The donor site remains relatively concealed, minimizing functional and aesthetic concerns. Additionally, when the flap is harvested with a sensory nerve and anastomosed to recipient site sensory nerves, it facilitates favorable sensory recovery outcomes. ³⁵

Advantages and disadvantages of the superior lateral malleolar perforator flap for wound reconstruction

Advantages

It does not damage the main vascular trunks, resulting in minimal donor site morbidity without compromising function or aesthetics.

The revascularization of the perforator flap adheres to normal physiological requirements.

If necessary, the flap can include the superficial peroneal nerve, which not only enhances the reliability of blood supply and increases the harvested flap area but also facilitates the recovery of sensory function.

The flap is relatively thin with minimal subcutaneous tissue, making it particularly suitable for dorsal foot wound coverage or free flap reconstruction of hand defects, yielding a less bulky and more aesthetically pleasing outcome.

The descending branch of the superior lateral malleolar artery flap, with its lowered pivot point, can be utilized for forefoot dorsal defect reconstruction.

The surgical procedure is relatively simple, requiring no specialized instruments or equipment, making it suitable for use in primary hospitals. ¹³

Disadvantages

During free transplantation of the superior lateral malleolar perforator flap, the small vessel diameter often necessitates anastomosis with finer recipient vessels, demanding a high level of expertise in microvascular anastomosis.

There is anatomical variation in the location and diameter of the perforator vessels. Intraoperative injury to these perforators may compromise flap perfusion, leading to surgical failure.

The small perforator vessels are susceptible to traction or torsion, which may trigger persistent vasospasm. ³⁶

Compared with reverse sural artery flap, the superior lateral malleolar flap provides a thinner, more pliable cover and avoids sacrifice of the sural nerve, resulting in superior two-point discrimination (4–6 mm vs. 10–12 mm) and lower donor-site paresthesia rates (8% vs. 37%). However, the reverse sural flap offers a longer arc of rotation (>15 cm) and is therefore preferable for calcaneal or distal-third leg defects. Compared with anterolateral thigh (ALT) perforator flap, the ALT flap supplies abundant soft tissue for composite defects, but its bulk frequently requires secondary debulking on the dorsum of the foot; the superior lateral malleolar flap remains the first choice for defects <60 cm² where contour and shoe-fit are critical. In summary, the superior lateral malleolar perforator flap is the technique of choice for thin, pliable coverage of small-to-moderate dorsal foot or hand defects in centers with microsurgical expertise; however, its role in larger or composite defects and in resource-limited settings remains debatable. Standardized imaging protocols and prospective comparative data are urgently needed to resolve these controversies.

Conclusions

Although the superior lateral malleolar perforator flap is one of the most ideal flaps for reconstructing defects in the lower leg, ankle, and foot and has been widely applied in clinical practice, various modifications and innovative transfer techniques continue to emerge. Despite a relatively well-established anatomical understanding of this flap, there remain variations in perforator location and vessel diameter. Although preoperative perforator mapping using portable Doppler, color Doppler ultrasound, magnetic resonance angiography, computed tomography angiography, and thermography has been widely utilized, these imaging modalities have not completely resolved these variations. Further anatomical studies are required to refine the understanding of vascular origins at different developmental stages, providing a stronger theoretical foundation for clinical reconstruction applications.